Healthcare Provider Details

I. General information

NPI: 1285964601
Provider Name (Legal Business Name): MICHELLE S PARADIS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2010
Last Update Date: 09/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 CEDAR ST
BANGOR ME
04401-6433
US

IV. Provider business mailing address

42 CEDAR ST
BANGOR ME
04401-6433
US

V. Phone/Fax

Practice location:
  • Phone: 207-947-0366
  • Fax: 207-942-4350
Mailing address:
  • Phone: 207-947-0366
  • Fax: 207-942-4350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberMC12173
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC13598
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: